Use of Text Messaging Services to Promote Health Behaviors in Children

Abstract

Objective

To examine adherence to, satisfaction with, and preliminary efficacy of mobile phone short message service (SMS) to promote health behaviors in school-aged children.

Methods

A total of 49 children (aged 8–10 years) were randomized by school classes into a monitoring vs no-monitoring group. All children participated in 2 educational group sessions that focused on health behaviors: the advantages of increasing fruit and vegetable consumption and physical activity, and decreasing screen time. The monitoring group also reported daily behavior using SMS and received supportive feedback for 8 weeks.

Results

Children submitted 61% of the required SMS, which indicated good adherence to the intervention. A number of children (95%) reported being satisfied with the program. Analyses of covariance indicated increase in fruit and vegetable consumption (χ² [2] = 7.27; P < .05) and a decrease in screen time (χ² [2] = 6.79; P < .05).

Conclusions and Implications

The current SMS intervention was a useful tool to monitor and promote health behaviors in children.

Introduction

The rise in childhood obesity has been drastic over the past decades and is one of the most serious public health challenges of the 21st century.¹ According to the International Association for the Study of Obesity, over 200 million school-aged children are overweight, which makes this generation the first predicted to have a shorter lifespan than their parents.² Childhood obesity is mainly associated with unhealthy diets and low physical activity. Health promotion and intervention programs for childhood obesity need to support and facilitate an increase in physical activity and healthier diets.

The use of new information and communication technologies has shown promising results in promoting health behaviors,³ preventing childhood obesity,⁴ and maintaining weight loss in overweight children.⁵ For example, the short message service (SMS) has proven to be useful in promoting health behaviors in children.⁶ In fact, SMS has been acceptable for providing support, effecting behavior change, and/or maintaining treatment gains in diabetes,⁷ asthma,⁸ smoking cessation,⁹ depressive symptoms,¹⁰ bulimia nervosa,¹¹ and childhood obesity.¹²

Children prefer novel devices, and technology-enhanced systems showed positive effects on participants' adherence rates.⁶ Furthermore, SMS has several advantages such as accessibility at any time, fast and instant information, guidance and advice without major effort (after messages are created), and low costs.¹³ The use of Internet and mobile phones has increased in the past 2 decades; according to Cardoso et al,¹⁴ 84.2% of children aged 9–12 years in Portugal own a mobile phone and 88% use it to type messages.

Bauer et al¹⁵ developed an Internet-based computer program used in previous research to provide support and promote behavior change via SMS. Methods from social cognitive theory and behavioral models were considered and used in developing the program. Self-monitoring and immediate feedback based on specific goals are important elements in behavioral theory. The idea that health behavior will change with specific goals when positive reinforcement is provided is based on social cognitive theory.¹⁶

Shapiro et al⁶ used an adopted version of the program developed by Bauer et al¹⁵ and showed that text messaging might be a useful tool for self-monitoring sugar-sweetened beverages, physical activity, and screen time. Children monitored target behaviors via SMS with feedback or via paper diaries, or participated in a no-monitoring condition. In the current study, the researchers adapted this program to promote health behaviors (eg, fruit and vegetable consumption, physical activity, screen time) in children. Compared with the study by Shapiro et al, children were randomized by classes into SMS monitoring vs no monitoring.⁶ The intervention consisted of an interaction between participants and provider via SMS. Participants sent text messages at regular intervals and received supportive feedback messages based on their entries.

The current pilot study aimed to explore participants' adherence to and satisfaction with the SMS-based monitoring and feedback system. A secondary aim of the pilot study was to explore the preliminary efficacy of the program to promote health behaviors. To test this aim, researchers hypothesized that the intervention group would report increased fruit and vegetable consumption and physical activity and decreased screen time.